Project summary Tracheal intubation (TI) is a common life-saving procedure for critically ill children, but associated with frequent complications and adverse safety outcomes. Currently, no single quality improvement (QI) intervention has proven effective to improve TI safety and reduce complications. With prior AHRQ R03 and Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) network support, we have already conducted a risk assessment using our robust multi-center pediatric TI safety registry: National Emergency Airway Registry for Children (NEAR-4-KIDS), with clear operational definitions and >95% compliance to capture key patient, provider and practice factors associated with preventable adverse events and TI failure. We have already assembled QI and content experts to develop a bundle of evidence-based safety interventions and a consensus implementation plan. The elements of the toolkit specifically include 1) TI planning with a risk factor review checklist, 2) a bedside time-out immediately before TI to review crew resource management/team roles, 3) a bedside time-out immediately after TI to reflect and debrief, and 4) quantitative debriefing among participating centers to share best practices on implementation of the safe practice intervention. This project will rigorously evaluate the clinical impact of our collaboratively developed NEAR4KIDS TI safe practice bundled intervention across a diverse spectrum of (large and small, academic and private) pediatric ICUs. Further, this project will identify and mitigate the safe bundled intervention uptake, adoption, implementation processes and variances at the individual site level. This approach includes standardized outcome measures using our NEAR4KIDS registry, measures of bundle adherence, safety culture, focus groups, and semi-structured interviews. We will employ mixed-method quantitative and qualitative analyses to identify the key factors and barriers for the safe practice bundled QI intervention adoption in diverse pediatric hospital settings. Based on these analyses, we will further refine the safe practice toolkit and implementation approach. The anticipated clinical impact of safe practice bundled intervention implementation will be measured prospectively by our NEAR4KIDS registry process of care measures, and most importantly by a meaningful absolute risk reduction in adverse TI associated events. We have access to large implementation networks including PALISI and the American Heart Association life support training programs poised to disseminate the toolkit beyond these 16 centers, at the completion of the 2 year AHRQ R18 project. Upon successful completion, we will have developed and refined a safe practice bundled intervention toolkit and evidence-based implementation and dissemination plan to improve the safe delivery of care across diverse hospital settings.